Recommendations by Queensland GPs to be more physically active: which patients were recommended which activities and what action they took

Objective: To ascertain the extent to which general practitioners in Queensland recommend physical activity to their patients, the types of patients they target, types of activities they suggest and how patients respond to the recommendations. Methods: Questions designed to answer the research objectives were included in the Queensland Social Survey. Univariate, bivariate and logistic regression analyses were employed linking relevant variables with demographic data from the survey. Results: The survey was completed by 1,261 (35.2%) people. In the previous year, 225 (18%) of them were recommended by a general practitioner to do more physical activity. These people were more likely to have a higher body mass index and rate their general health as fair or poor. Walking was the most common activity recommended (75%). Only 18% of people were not pleased to be recommended to take more exercise and most (67%) reported following the advice. Blue‐collar workers and older people were less likely to follow the recommendations. Conclusions: General practitioners in Queensland are recommending increased physical activity to patients with weight problems and with medical problems. Patients are usually pleased to receive the advice and act upon it. Implications: General practitioners should be aware that physical activity recommendations are received favourably by most patients and there is potential to improve public health by giving physical activity advice to sedentary and/or overweight patients when appropriate.     

Direct observation and patient recall of health behavior advice

BACKGROUND: Patient recall of health behavior change discussions with physicians is an important intermediate outcome to adherence with recommendations and subsequent behavior change. This study reports patient recall of health behavior discussions during outpatient visits and tests patient and visit characteristics associated with recall. METHODS: In a cross-sectional study of 2670 adult outpatients visiting 138 family physicians in 84 practices, provision of health behavior advice was measured by direct observation. Patient recall of discussion of each health behavior topic was assessed by patient survey. RESULTS: Patient recall rates ranged from 11% for substance use assessment to 75% of smokers recalling smoking cessation advice. Patient demographics were not associated with recall. In multivariable models, the strongest predictor of patient recall of diet and exercise advice was the duration of the advice. Advice provided during well care visits was more likely to be recalled by patients than during illness visits, but presence of a health behavior-relevant diagnosis during an illness visit was associated with a 2-fold increase in patient recall. CONCLUSIONS: Patient recall of health behavior advice is enhanced by longer duration of advice and by linking advice to visit contexts that represent teachable moments.     

Fibromyalgia, cognitive problems and independence: physical activity may be useful in home health care

Home health care providers often deal with older clients who have cognitive deficits. Cognitive problems have a negative impact on independence. Certain chronic pain conditions present with cognitive dysfunction as a co-morbidity. Fibromyalgia syndrome is one such condition. Home health care providers need to know that mild-moderate exercise may positively affect fibromyalgia-related cognitive deficits at very low cost. All of the above is discussed in this paper along with advice concerning the provision of exercise for older, home bound people.     

“What My Doctor Didn't Tell Me”: Examining Health Care Provider Advice to Overweight and Obese Pregnant Women on Gestational Weight Gain and Physical Activity

BackgroundAppropriate gestational weight gain (GWG) is vital, as excessive GWG is strongly associated with postpartum weight retention and long-term obesity. How health care providers counsel overweight and obese pregnant women on appropriate GWG and physical activity remains largely unexplored.MethodsWe conducted semistructured interviews with overweight and obese women after the birth of their first child to ascertain their experiences with GWG. A grounded theory approach was used to identify themes on provider advice received about GWG and physical activity during pregnancy.ResultsTwenty-four women were included in the analysis. Three themes emerged in discussions regarding provider advice on GWG: 1) Women were advised to gain too much weight or given no recommendation for GWG at all, 2) providers were perceived as being unconcerned about excessive GWG, and 3) women desire and value GWG advice from their providers. On the topic of provider advice on exercise in pregnancy, three themes were identified: 1) Women received limited or no advice on appropriate physical activity during pregnancy, 2) women were advised to be cautious and limit exercise during pregnancy, and 3) women perceived that provider knowledge on appropriate exercise intensity and frequency in pregnancy was limited.ConclusionsThis study suggests that provider advice on GWG and exercise is insufficient and often inappropriate, and thus unlikely to positively influence how overweight and obese women shape goals and expectations in regard to GWG and exercise behaviors. Interventions to help pregnant women attain healthy GWG and adequate physical activity are needed.     

The descriptive epidemiology of a sedentary lifestyle in adult Australians.

Regular exercise is important for the maintenance of good health, but many people do very little exercise. There are public health concerns about activating the sedentary and, from an epidemiological measurement perspective, there are advantages in assessing physical inactivity. Using pooled data from 17,053 participants in Australian population surveys, we identified 5078 people (29.7%) who could be classified as sedentary in their recreational exercise habits. Logistic regression analyses found the inactive to be more likely to be older, less well educated, and to have lower incomes. The main reasons given for not exercising were no time (33%), being physically unable (23%), and not wanting to exercise (13%): these were more likely to be reported by those who were older, and who had lower incomes; the only exception was that being 55 years or older was not associated with having less time. Women were more likely to report being physically unable to exercise. Lower income was associated with being physically unable, and with not wanting to exercise. Those with children, while wanting to exercise, were more likely to report having no time. The greatest health benefits will result from the sedentary becoming more active, and inexpensive and convenient activities such as walking need to be emphasized.     

Direct observation of exercise counseling in community family practice

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.     

Randomized controlled trial of physical activity counseling for older primary care patients

BACKGROUND: Regular physical activity reduces the risk for chronic diseases among older adults. Older adults are likely to be seen by primary care clinicians who can play a role in promoting physical activity among their patients. DESIGN: In this randomized controlled trial (1998-2003; data analyzed 2004-2005), we compared the effects of brief advice to exercise from a clinician supplemented by telephone-based counseling by health educators (extended advice) to brief advice from a clinician alone (brief advice). SETTING/PARTICIPANTS: A total of 100 primary care patients (63.2% female, 14.7% minority, mean age=68.5 years) participated in the trial. INTERVENTIONS: The extended-advice intervention consisted of clinician advice plus exercise counseling via telephone provided by research staff, and the brief advice condition consisted of clinician advice alone. Both interventions focused on promoting moderate-intensity physical activity. MAIN OUTCOME MEASURES: Self-reported physical activity using the 7-Day Physical Activity Recall instrument and objective activity monitoring using Biotrainers were assessed at baseline, and at 3 and 6 months. RESULTS: Participants in the extended-advice arm reported significantly greater participation in moderate-intensity physical activity than the brief-advice group at 3 months (+57.69 minutes vs 12.45 minutes; 3.84 kcal/week vs 0.83 kcal/week) and 6 months (+62.84 minutes vs 16.60 minutes; 4.19 kcal/week vs 1.1 kcal/week). Objective activity monitoring also showed significantly increased physical activity among extended-advice versus brief-advice participants at both time points (+50.79 vs -11.11; +42.39 vs -24.18, respectively). CONCLUSIONS: These data indicate that clinician advice with follow-up counseling can promote adoption of moderate-intensity physical activity among older, primary care patients.     

What prevents older people from seeking treatment for urinary incontinence? A qualitative exploration of barriers to the use of community continence services

BACKGROUND: Urinary incontinence is a significant health problem for older people. Many people with incontinence do not seek services. Simple and effective treatments exist in primary care. OBJECTIVES: Our aim was to explore reasons why older people living in the community do not present for help with problems of urinary incontinence and to identify ways in which they may be assisted to access continence services. METHODS: In-depth interviews lasting an average of 1 h were conducted with 20 people aged over 65 years living in the community, purposively selected from a sample of patients who volunteered to be interviewed. RESULTS: Older people described ageing as a natural, degenerative process and had reduced health expectations. Urinary incontinence was commonly viewed as an inevitable aspect of ageing and, as such, something to be accepted and managed independently. Shame and embarrassment combined with generational differences in attitudes to disclosure about personal matters also prevented people from seeking advice. Relatively successful strategies to manage incontinence enabled people to contain their symptoms, although this was at a social, psychological and, in some cases, health cost. Older people in this sample had considerable co-morbidity, in many cases resulting in mobility problems. Despite regular contact with primary care professionals, they had seldom disclosed their urinary incontinence. CONCLUSION: A combination of personal attitudes and practical barriers prevent older people from seeking help for urinary incontinence. It is possible that older people would be more likely to seek help if asked specifically about urinary leakage by primary health care professionals.     

Prevalence of leisure-time and occupational physical activity among employed adults--United States, 1990

Regular physical activity and high levels of physical fitness offer numerous health benefits, such as reduced risk for cardiovascular disease, diabetes, obesity, some cancers, and musculoskeletal conditions (1). National rates for participation in leisure-time physical activity are consistently low for women, older adults, persons with low educational attainment, and racial/ethnic minorities (2). Public health recommendations for promoting physical activity emphasize moderate-intensity activities, building on recommendations for vigorous exercise to improve fitness (3,4). To determine the prevalence of leisure-time and occupational physical activity, data were analyzed for employed adults aged > or = 18 years in the 1990 National Health Interview Survey (NHIS). This report summarizes the results of the survey, which indicate that approximately half of adults who reported no physical activity during leisure time also reported that they performed at least 1 hour per day of hard physical activity at work.     

Staff perspectives on the barriers and facilitators to exercise implementation in inpatient mental health services: A qualitative study

Exercise has multiple benefits for the physical and mental health of people with severe mental health problems (SMI). However, people with SMI engage in significantly less exercise than the general population and there is an evidence-practice gap regarding the implementation of exercise in clinical services. Mental health staff in inpatient services are well placed to support people with SMI to exercise, yet little is known about staff perspectives on exercise facilitation in inpatient care. This study aimed to explore staff views on role for exercise for people with SMI and the barriers and facilitators to exercise implementation in inpatient services. Qualitative semi-structured interviews were conducted with 25 clinicians working in inpatient mental health settings. Interview topics included the role for exercise in inpatient services, staff roles in relation to exercise, the barriers and facilitators to patients’ engagement in exercise, and promotion of exercise. Interview data were analysed using Thematic Analysis. Four key themes were developed: (i) perceived patient factors, (ii) exercise in the context of relationships, (iii) the ward context, and (iv) the therapeutic role for exercise. Clinicians readily recognised the benefits of service users engaging in exercise, though identified a number of individual, systemic, and organisational barriers to exercise implementation in inpatient services. Organisational prioritisation of exercise and support for staff to develop their skills and confidence in exercise facilitation is required. Enhancing the legitimacy of exercise as a multi-beneficial intervention for people with SMI is essential. Further recommendations for services based on the study findings are provided.     

Relationship between regular exercise and life style, social network, education and subjective symptoms in Japanese middle aged and elderly residents]

OBJECT AND METHODS: A community-based survey of 12,630 residents of Gunma Prefecture aged 40 to 69 years was conducted to investigate the relationship between the habit of regular exercise and life style, social network, and subjective physical and mental symptoms in particular. The subjective physical and mental symptoms were measured using the Todai Health Index (THI). The response rate was 91.6%. A total of 6,736 responses were analyzed after excluding respondents with chronic diseases from the analysis. On the question about the habit of regular exercise ("Do you exercise regularly?"), the responses were divided into three categories: 1. Often, 2. Sometimes, 3. Hardly ever or Never. RESULTS AND CONCLUSION: The results are summarized as follows: 1. The proportions of residents who exercise "often" were 14.2% and 11.1% for males and females, respectively, while those of "hardly ever or never" were 52.3% and 59.4% for males and females, respectively. More males than females had the habit of regular exercise. Respondents were divided into three age categories: 40-49, 50-59 and 60-69 years. Among the female respondents, it was shown that the older the age category the greater the habit of regular exercise. 2. Both male and female respondents who had regular exercise habits scored significantly lower on the THI scales for vague complaints, depression, and irregularity of life, while they scored higher on the aggression and lie (social desirability) scales. 3. Both male and female respondents who had regular exercise habits also tended to have be better perceived health and social networking, i.e. having close friends, having a hobby and involvement in community social activities, as well as taking care of pets. This group also had a higher average education level and less of a smoking habit. This study suggests that regular exercise habit correlates not only with physical health and fitness levels but with mental health status as well.     

Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization

PURPOSE: To identify factors associated with receipt of physician advice on diet and exercise, including patient sociodemographic characteristics, health-related needs, and health care access, using Andersen's model of health care utilization. DESIGN: A cross-sectional analysis was performed using data from the 2000 National Health Interview Survey (NHIS). SETTING: NHIS data were collected through personal household interviews by Census interviewers. The overall response rate for the 2000 NHIS adult sample was 82.6%. SUBJECTS: Subjects were a representative sample of the American civilian, noninstitutionalized population aged 18 and older. After eliminating missing data and respondents who reported they did not see a doctor in the past 12 months, sample sizes for physician advice on diet and exercise were n = 26,255 and n = 26,158, respectively. MEASURES: Using the 2000 NHIS, the prevalence of receipt of physician advice on diet and exercise was assessed. Multiple logistic regression analyses were performed to examine the associations between receipt of physician advice on diet and exercise and potential predictors, adjusting for all covariates. RESULTS: By self-report, 21.3% and 24.5% of respondents received physician advice on diet and exercise, respectively. Being middle-aged (adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI], 1.0-1.29 for diet; AOR = 1.55, 95% CI = 1.33-1.79 for exercise) and having a baccalaureate degree or higher (AOR = 1.78, 95% CI = 1.52-2.08 for diet; AOR = 1.75, 95% CI = 1.47-2.07) were associated with a higher likelihood of receiving physician advice on diet and exercise. African-Americans (AOR = .78, 95% CI = .67-.92) and foreign-born immigrants (AOR = .57, 95% CI = .38-.86) were less likely to receive physician advice on exercise. The prevalence of physician advice was higher for persons who chose hospital outpatient departments as a usual source for care (AOR = 2.36, 95% CI = 1.66-3.36 for diet; AOR = 2.39, 95% CI = 1.68-3.4 for exercise) than for adults with other types of usual care sites. Poorer self-rated health status (AOR = 5.2, 95% CI = 4.12-6.57 for diet; AOR = 2.63, 95% CI = 2.04-3.38 for exercise) and obesity (AOR = 2.32, 95% CI = 2.02-2.66 for diet; AOR = 3.01, 95% CI = 2.46-3.69 for exercise) was positively associated with the likelihood of receiving physician advice on diet and exercise. CONCLUSIONS: Effective strategies to increase receipt of physician advice should include efforts to improve access to regular source of care and patient-physician communication. Sociodemographic factors remain independent and important predictors of who obtains such advice.     

Application of a falls prevention program for older people to primary health care practice

BACKGROUND: Our research group has established the effectiveness of an individually tailored home exercise program to prevent falls and fall injuries in older people in four controlled trials. In one of these trials we evaluated the applicability of the exercise program to routine primary health care practice and the feasibility of nurses implementing the program. METHODS: People aged 80 years and older, registered with general practices in three exercise (n = 330 participants) and four control centers (n = 120 participants) in New Zealand, were invited to take part by their doctor. We investigated program reach, uptake, and compliance. We carried out physical assessments at baseline and after 1 year to assess the impact of the program. RESULTS: Most (85%) doctors agreed to take part and they approved 71% of patients to undertake the exercise program. Overall 47% of people invited agreed to participate and 70% of the exercise participants remained exercising at 1 year. Balance score and chair stand time improved by a similar amount in each exercise center compared with the control centers. CONCLUSIONS: This falls prevention program is acceptable to older people and their doctors. Nurses trained by a physiotherapist can deliver the home exercise program effectively in routine primary health care practice.     

Older women and exercise: explanatory concepts.

BACKGROUND: Older women remain predominantly sedentary despite potential health benefits and reduced risks of cardiovascular disease associated with regular exercise. Primary care interventions to increase exercise need to focus on constructs amenable to intervention that predict exercise behavior. PURPOSE: The study tested an explanatory model of older women's exercise behavior using concepts from social cognitive theory, the transtheoretical model, and the theory of planned behavior (self-efficacy, outcome expectancy, perceived exercise barriers, processes of change, perceived health, and age). METHODS: Data were collected by interviews with 203 older community-dwelling women physically capable of some exercise. Ordinary least squares regression results were used to determine the direct and indirect effects in a path model. FINDINGS: All concepts and 13 hypothesized paths were retained in the trimmed model. The constructs accounted for 46% of the variance in exercise behavior. Outcome expectancy had the largest total effect. Processes of change had the largest direct effect on exercise behavior. Exercise self-efficacy and perceived exercise barriers accounted for similar amounts of variance in exercise behavior, whereas age and health had only modest effects. CONCLUSION: Important constructs for future exercise model testing and intervention research should include outcome expectancy, processes of change, exercise self-efficacy, and perceived barriers to exercise. Primary care interventions designed to increase older women's exercise should focus on these same constructs.     

Incorporating physical activity advice into primary care: physician-delivered advice within the activity counseling trial

INTRODUCTION: The Activity Counseling Trial (ACT) was designed to compare the effectiveness of physician advice alone with physician advice plus behavioral counseling, provided by ACT-trained health educators, to increase levels of physical activity in healthy, sedentary patients. The objective was to determine health care providers' adherence to the ACT protocol for delivering initial "physician" advice on physical activity and to determine providers' satisfaction with the protocol. METHODS: Fifty-four physicians or physician assistants from 11 primary care practices located in California, Texas, and Tennessee volunteered to participate as ACT-trained physicians. Providers were trained to integrate 3 to 4 minutes of initial physical activity advice into the routine office visits of sedentary patients, aged 35 to 75 years, with no acute or serious chronic conditions. This advice included assessment of current physical activities, advising the patient about an appropriate physical activity goal, and referring the patient to the health educator. Providers initialed forms to document delivery of advice, and ACT health educators recorded their advice on a computerized tracking system. A provider survey measured length of time spent advising patients about physical activity and provider satisfaction with the program. RESULTS: Ninety-nine percent of patients received the initial physician advice about physical activity. Eighty-three percent of the providers spent less than 5 to 6 minutes, and 46% spent the recommended 3 to 4 minutes providing advice. Sixty-three percent said the advice resulted in little or no increase in the length of an office visit, and 83% said participation was an asset to their clinics. CONCLUSIONS: Providers incorporated brief physical activity advice into routine primary care visits with little disruption. Their response to the ACT advice protocol was positive and participation in the study was viewed as beneficial.     

Determinants of participation in a health education and exercise program on television

BACKGROUND: The daily television program 'the Netherlands on the Move' (NOM-tv), which primarily targets people aged over 55 (estimated Dutch 55+ population: 4 million), was designed as part of a national campaign for promoting physical activity. The aim of the study was to identify the determinants of exercise participation and viewing NOM-tv. METHODS: The method used was baseline test by quota digit dialing in the country (n = 988, stratified age 35+ and 55+), and follow-up after 7 months (n = 362). The main outcome measures are: intention and actual participation in exercises. The determinants are: attitude, social influences, self-efficacy, age, sex, education, knowledge about the health effects of exercise, habits, stage of change in exercising, and perceived barriers. The backgrounds were: marital status, living situation, mental health and vitality. RESULTS: NOM-tv attracted at least 21% of the physically non-active people at baseline to viewing and increased knowledge. The best predictors of intention to participate were: attitude, social influences, self-efficacy, age and gender. Actual participation was best predicted by age (higher), gender (female), intention, knowledge, and the (lower) number of perceived barriers. CONCLUSIONS: NOM-tv is a successful (high number of viewers) and relatively cheap way of getting inactive, older people-especially women-to exercise.     

What is the impact of day care on older people with long-term conditions: A systematic review

There is a lack of robust evidence regarding outcomes for day care use among older people living with long-term conditions (LTCs). Day care is provided by independent, private and voluntary and charitable sectors. This systematic review aims to establish current evidence of outcomes for older people with LTCs attending day care services and outcomes on carers, across all service models. Narrative synthesis of quantitative and qualitative data was undertaken. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was carried out across eight electronic databases and reference lists of key journals between 2004 and October 2020 were searched. Searches returned 1,202 unique titles. Forty-five articles from 16 countries met the criteria on review of title, abstract and full article. There is limited evidence suggesting improved levels of perceived psychological health, quality of life, perceived general health, physical health and functioning for older people attending day care who have LTCs. The respite function of day care resulted in positive outcomes for carers. Studies evaluating outcomes for participants or carers were limited in quantity and quality. There is limited information regarding outcomes for day care attendance for older people with multiple LTCs from existing literature. Further research focusing on LTCs and day care attendance would benefit this field.     

Randomised controlled trial of a complex intervention by primary care nurses to increase walking in patients aged 60–74 years: protocol of the PACE-Lift (Pedometer Accelerometer Consultation Evaluation - Lift) trial

Background

Physical activity is essential for older peoples’ physical and mental health and for maintaining independence. Guidelines recommend at least 150 minutes weekly, of at least moderate intensity physical activity, with activity on most days. Older people’s most common physical activity is walking, light intensity if strolling, moderate if brisker. Less than 20% of United Kingdom 65–74 year olds report achieving the guidelines, despite most being able to. Effective behaviour change techniques include strategies such as goal setting, self-monitoring, building self-efficacy and relapse prevention. Primary care physical activity consultations allow individual tailoring of advice. Pedometers measure step-counts and accelerometers measure physical activity intensity. This protocol describes an innovative intervention to increase walking in older people, incorporating pedometer and accelerometer feedback within a primary care nurse physical activity consultation, using behaviour change techniques.

Methods/Design

Design: Randomised controlled trial with intervention and control (usual care) arms plus process and qualitative evaluations. Participants: 300 people aged 60–74 years registered with 3 general practices within Oxfordshire and Berkshire West primary care trusts, able to walk outside and with no restrictions to increasing their physical activity. Intervention: 3 month pedometer and accelerometer based intervention supported by practice nurse physical activity consultations. Four consultations based on behaviour change techniques, physical activity diary, pedometer average daily steps and accelerometer feedback on physical activity intensity. Individual physical activity plans based on increasing walking and other existing physical activity will be produced. Outcomes: Change in average daily steps (primary outcome) and average time spent in at least moderate intensity physical activity weekly (secondary outcome) at 3 months and 12 months, assessed by accelerometry. Other outcomes include quality of life, mood, exercise self-efficacy, injuries. Qualitative evaluations will explore reasons for trial non-participation, the intervention’s acceptability to patients and nurses and factors enhancing or acting as barriers for older people in increasing their physical activity levels.

Discussion

The PACE-Lift trial will determine the feasibility and efficacy of an intervention for increasing physical activity among older primary care patients. Steps taken to minimise bias and the challenges anticipated will be discussed. Word count 341.

Trial registration number

ISRCTN42122561